Pulmonary Embolism and Nursing Intervention

acute-massive-pulmonary-embolism
Pulmonary Embolism

–    PE: obstruction in the pulmonary vessels that obstructs blood flow.
–    The embolus travels from the venous circulation to the right side of the heart and pulmonary artery obstructing blood flow and resulting increase pulmonary arterial pressure and increase right ventricular work to maintain blood flow. When the work requirement of the right ventricular exceed its capacity, right ventricular failure and decrease in cardiac output followed by decrease BP and development of shock and pulmonary infarction.
–    Types of embolism: blood clot, air, fat, amniotic fluid, and septic (bacteria)

Etiology

 

–    Prolonged immobilization
–    Central venous catheters
–    Abdominal, pelvic or thoracic surgery
–    Obesity
–    Advancing age
–    Hyper-coagulability
–    History of thrombo-embolism
–    Cancer diagnosis
–    Venous stasis
–    Thrombophlebitis
–    Pregnancy and use of contraceptive.

Clinical Manifestations

–    Respiratory manifestations: dyspnea, tachypnea, tachycardia, pleuritic chest pain, dry cough, hemoptysis
–    Cardiac manifestations: distended neck veins, hypotension, abnormal heart sounds, abnormal electrocardiogram findings, cyanosis.
–    Low-grade fever, petechiae.
–     Presence of venous thrombosis in lower limbs.
–     Sudden death (massive pulmonary embolism).

Diagnostic Test Results

•    ABGs levels show respiratory alkalosis and hypoxemia.
•    Pulmonary angiography shows location of embolism and filling defect of pulmonary artery.
•    Physical findings: clinical signs and symptoms.
•    Chest X-ray shows dilated pulmonary arteries, penumoconstriction, diaphragm elevation on the affected side.
•    Radioisotope lung scan.

Treatment and Intervention


-    Bed rest with active and passive range of motion.
–    Keep the patient with  fowler position to enhance ventilation.
–    Assist with turning, coughing, and deep breathing to mobilize secretions and clear airway.
–    Assess respiratory status to detect respiratory distress.
–    Assess cardiovascular status. An irregular pulse may signal arrhythmia caused by hypoxemia. If cause of PE by thrombophlebitis, temperature may be elevated.
–    Administer O2 to enhance oxygenation.
–    Establish an IV line for fluids and drugs.
–    Monitor and record intake and output to detect fluid volume overload and renal perfusion.
–    ABGs monitoring to evaluate the need for mechanical ventilation.
–    Monitor laboratory studies because patient on heparin and need to evaluate electrolyte, CBC and Hct.
-    Anticoagulant drugs:
-    Heparin (IV): stop further thrombus formation and extended the clotting time, need adjustment for dosage to maintain the activated partial thromboplastine time (PTT).
–    Warfarine sodium (coumadin): may given simultaneously at the beginning or after 5-6  days of heparin therapy, dosage is controlled by monitoring of prothrombin time (PT) or after 5 of heparin therapy.
–    Thrombolytic agents
–    Streptokinase-  lyses thrombi in deep venous system and emboli in pulmonary circulation, causing more rapid resolution of the thrombi/emboli and restoring  pulmonary circulation to normal, improve circulatory and hemodynamic status.
•    Thrombolytic therapy usually followed with heparin and warfarin treatment to prevent additional thrombus formation.
•    Morphine are given to reduce chest pain and anxiety.
•    Diuretics: lasix if right ventricular failure develops.
•    Surgical intervention: embolectomy, inferior vena cava interruption.

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